BANGOR WATER DISTRICT

Backflow Test Results

Mail to: PO Box 1129, Bangor ME 04402-1129

Name _________________________________________

Address __________________________________________

Device Information

Make _______________________ Size ______________ inches

Model ______________________ Serial # ___________________

Test Results

Test Date ______________________________

First Check ______________________________ psid

Second Check ______________________________ psid

#2 Gate Valve ______________________________ psid

Vent Discharge _______________________________ psid

Tested by _______________________________

Company _______________________________

Certification No. ___________________________